Lateral-Entry Pin Fixation in the Management of Supracondylar Fractures in Children
BackgroundThere has been controversy regarding the optimal pin configuration in the management of supracondylar humeral fractures in children. A crossed-pin configuration may be mechanically more stable than lateral pins in torsional loading, but it is associated with a risk of iatrogenic injury to...
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| Published in | Journal of bone and joint surgery. American volume Vol. 86; no. 4; pp. 702 - 707 |
|---|---|
| Main Authors | , , , , |
| Format | Journal Article |
| Language | English |
| Published |
Boston, MA
Copyright by The Journal of Bone and Joint Surgery, Incorporated
01.04.2004
Journal of Bone and Joint Surgery Incorporated Journal of Bone and Joint Surgery AMERICAN VOLUME |
| Edition | American volume |
| Subjects | |
| Online Access | Get full text |
| ISSN | 0021-9355 1535-1386 |
| DOI | 10.2106/00004623-200404000-00006 |
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| Abstract | BackgroundThere has been controversy regarding the optimal pin configuration in the management of supracondylar humeral fractures in children. A crossed-pin configuration may be mechanically more stable than lateral pins in torsional loading, but it is associated with a risk of iatrogenic injury to the ulnar nerve. Previous clinical studies have suggested that lateral pins provide sufficient fixation of unstable supracondylar fractures. However, these studies were retrospective and subject to patient-selection bias.MethodsA displaced supracondylar humeral fracture was fixed with only lateral-entry pins in 124 consecutively managed children. Medical records and radiographs were reviewed to identify any complications, including loss of fracture reduction, iatrogenic ulnar nerve injury, infection, loss of motion of the elbow, and the need for additional surgery. In addition, eight displaced supracondylar humeral fractures that had been reduced and fixed with lateral pins at other institutions and had lost reduction were analyzed to determine the causes of the failures.ResultsSixty-nine children had a type-2 fracture, according to Wilkinsʼs modification of Gartlandʼs classification system; forty-three (62%) of those fractures were stabilized with two pins and twenty-six (38%), with three pins. Fifty-five children had a type-3 fracture; nineteen (35%) of those fractures were stabilized with two pins and thirty-six (65%), with three pins. A comparison of perioperative and final radiographs showed no loss of reduction of any fracture. There was also no clinically evident cubitus varus, hyperextension, or loss of motion. There were no iatrogenic nerve palsies, and no patient required additional surgery. One patient had a pin-track infection. Our analysis of the eight clinical and radiographic failures of lateral pin fixation that were not part of the consecutive series showed that the loss of fixation was due to fundamental technical errors.ConclusionsIn this large, consecutive series without selection bias, the use of lateral-entry pins alone was effective for even the most unstable supracondylar humeral fractures. There were no iatrogenic ulnar nerve injuries, and no reduction was lost. The important technical points for fixation with lateral-entry pins are (1) maximize separation of the pins at the fracture site, (2) engage the medial and lateral columns proximal to the fracture, (3) engage sufficient bone in both the proximal segment and the distal fragment, and (4) maintain a low threshold for use of a third lateralentry pin if there is concern about fracture stability or the location of the first two pins.Level of EvidenceTherapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence. |
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| AbstractList | BackgroundThere has been controversy regarding the optimal pin configuration in the management of supracondylar humeral fractures in children. A crossed-pin configuration may be mechanically more stable than lateral pins in torsional loading, but it is associated with a risk of iatrogenic injury to the ulnar nerve. Previous clinical studies have suggested that lateral pins provide sufficient fixation of unstable supracondylar fractures. However, these studies were retrospective and subject to patient-selection bias.MethodsA displaced supracondylar humeral fracture was fixed with only lateral-entry pins in 124 consecutively managed children. Medical records and radiographs were reviewed to identify any complications, including loss of fracture reduction, iatrogenic ulnar nerve injury, infection, loss of motion of the elbow, and the need for additional surgery. In addition, eight displaced supracondylar humeral fractures that had been reduced and fixed with lateral pins at other institutions and had lost reduction were analyzed to determine the causes of the failures.ResultsSixty-nine children had a type-2 fracture, according to Wilkinsʼs modification of Gartlandʼs classification system; forty-three (62%) of those fractures were stabilized with two pins and twenty-six (38%), with three pins. Fifty-five children had a type-3 fracture; nineteen (35%) of those fractures were stabilized with two pins and thirty-six (65%), with three pins. A comparison of perioperative and final radiographs showed no loss of reduction of any fracture. There was also no clinically evident cubitus varus, hyperextension, or loss of motion. There were no iatrogenic nerve palsies, and no patient required additional surgery. One patient had a pin-track infection. Our analysis of the eight clinical and radiographic failures of lateral pin fixation that were not part of the consecutive series showed that the loss of fixation was due to fundamental technical errors.ConclusionsIn this large, consecutive series without selection bias, the use of lateral-entry pins alone was effective for even the most unstable supracondylar humeral fractures. There were no iatrogenic ulnar nerve injuries, and no reduction was lost. The important technical points for fixation with lateral-entry pins are (1) maximize separation of the pins at the fracture site, (2) engage the medial and lateral columns proximal to the fracture, (3) engage sufficient bone in both the proximal segment and the distal fragment, and (4) maintain a low threshold for use of a third lateralentry pin if there is concern about fracture stability or the location of the first two pins.Level of EvidenceTherapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence. There has been controversy regarding the optimal pin configuration in the management of supracondylar humeral fractures in children. A crossed-pin configuration may be mechanically more stable than lateral pins in torsional loading, but it is associated with a risk of iatrogenic injury to the ulnar nerve. Previous clinical studies have suggested that lateral pins provide sufficient fixation of unstable supracondylar fractures. However, these studies were retrospective and subject to patient-selection bias. A displaced supracondylar humeral fracture was fixed with only lateral-entry pins in 124 consecutively managed children. Medical records and radiographs were reviewed to identify any complications, including loss of fracture reduction, iatrogenic ulnar nerve injury, infection, loss of motion of the elbow, and the need for additional surgery. In addition, eight displaced supracondylar humeral fractures that had been reduced and fixed with lateral pins at other institutions and had lost reduction were analyzed to determine the causes of the failures. Sixty-nine children had a type-2 fracture, according to Wilkins's modification of Gartland's classification system; forty-three (62%) of those fractures were stabilized with two pins and twenty-six (38%), with three pins. Fifty-five children had a type-3 fracture; nineteen (35%) of those fractures were stabilized with two pins and thirty-six (65%), with three pins. A comparison of perioperative and final radiographs showed no loss of reduction of any fracture. There was also no clinically evident cubitus varus, hyperextension, or loss of motion. There were no iatrogenic nerve palsies, and no patient required additional surgery. One patient had a pin-track infection. Our analysis of the eight clinical and radiographic failures of lateral pin fixation that were not part of the consecutive series showed that the loss of fixation was due to fundamental technical errors. In this large, consecutive series without selection bias, the use of lateral-entry pins alone was effective for even the most unstable supracondylar humeral fractures. There were no iatrogenic ulnar nerve injuries, and no reduction was lost. The important technical points for fixation with lateral-entry pins are (1) maximize separation of the pins at the fracture site, (2) engage the medial and lateral columns proximal to the fracture, (3) engage sufficient bone in both the proximal segment and the distal fragment, and (4) maintain a low threshold for use of a third lateral-entry pin if there is concern about fracture stability or the location of the first two pins. There has been controversy regarding the optimal pin configuration in the management of supracondylar humeral fractures in children. A crossed-pin configuration may be mechanically more stable than lateral pins in torsional loading, but it is associated with a risk of iatrogenic injury to the ulnar nerve. Previous clinical studies have suggested that lateral pins provide sufficient fixation of unstable supracondylar fractures. However, these studies were retrospective and subject to patient-selection bias.BACKGROUNDThere has been controversy regarding the optimal pin configuration in the management of supracondylar humeral fractures in children. A crossed-pin configuration may be mechanically more stable than lateral pins in torsional loading, but it is associated with a risk of iatrogenic injury to the ulnar nerve. Previous clinical studies have suggested that lateral pins provide sufficient fixation of unstable supracondylar fractures. However, these studies were retrospective and subject to patient-selection bias.A displaced supracondylar humeral fracture was fixed with only lateral-entry pins in 124 consecutively managed children. Medical records and radiographs were reviewed to identify any complications, including loss of fracture reduction, iatrogenic ulnar nerve injury, infection, loss of motion of the elbow, and the need for additional surgery. In addition, eight displaced supracondylar humeral fractures that had been reduced and fixed with lateral pins at other institutions and had lost reduction were analyzed to determine the causes of the failures.METHODSA displaced supracondylar humeral fracture was fixed with only lateral-entry pins in 124 consecutively managed children. Medical records and radiographs were reviewed to identify any complications, including loss of fracture reduction, iatrogenic ulnar nerve injury, infection, loss of motion of the elbow, and the need for additional surgery. In addition, eight displaced supracondylar humeral fractures that had been reduced and fixed with lateral pins at other institutions and had lost reduction were analyzed to determine the causes of the failures.Sixty-nine children had a type-2 fracture, according to Wilkins's modification of Gartland's classification system; forty-three (62%) of those fractures were stabilized with two pins and twenty-six (38%), with three pins. Fifty-five children had a type-3 fracture; nineteen (35%) of those fractures were stabilized with two pins and thirty-six (65%), with three pins. A comparison of perioperative and final radiographs showed no loss of reduction of any fracture. There was also no clinically evident cubitus varus, hyperextension, or loss of motion. There were no iatrogenic nerve palsies, and no patient required additional surgery. One patient had a pin-track infection. Our analysis of the eight clinical and radiographic failures of lateral pin fixation that were not part of the consecutive series showed that the loss of fixation was due to fundamental technical errors.RESULTSSixty-nine children had a type-2 fracture, according to Wilkins's modification of Gartland's classification system; forty-three (62%) of those fractures were stabilized with two pins and twenty-six (38%), with three pins. Fifty-five children had a type-3 fracture; nineteen (35%) of those fractures were stabilized with two pins and thirty-six (65%), with three pins. A comparison of perioperative and final radiographs showed no loss of reduction of any fracture. There was also no clinically evident cubitus varus, hyperextension, or loss of motion. There were no iatrogenic nerve palsies, and no patient required additional surgery. One patient had a pin-track infection. Our analysis of the eight clinical and radiographic failures of lateral pin fixation that were not part of the consecutive series showed that the loss of fixation was due to fundamental technical errors.In this large, consecutive series without selection bias, the use of lateral-entry pins alone was effective for even the most unstable supracondylar humeral fractures. There were no iatrogenic ulnar nerve injuries, and no reduction was lost. The important technical points for fixation with lateral-entry pins are (1) maximize separation of the pins at the fracture site, (2) engage the medial and lateral columns proximal to the fracture, (3) engage sufficient bone in both the proximal segment and the distal fragment, and (4) maintain a low threshold for use of a third lateral-entry pin if there is concern about fracture stability or the location of the first two pins.CONCLUSIONSIn this large, consecutive series without selection bias, the use of lateral-entry pins alone was effective for even the most unstable supracondylar humeral fractures. There were no iatrogenic ulnar nerve injuries, and no reduction was lost. The important technical points for fixation with lateral-entry pins are (1) maximize separation of the pins at the fracture site, (2) engage the medial and lateral columns proximal to the fracture, (3) engage sufficient bone in both the proximal segment and the distal fragment, and (4) maintain a low threshold for use of a third lateral-entry pin if there is concern about fracture stability or the location of the first two pins. BACKGROUND: There has been controversy regarding the optimal pin configuration in the management of supracondylar humeral fractures in children. A crossed-pin configuration may be mechanically more stable than lateral pins in torsional loading, but it is associated with a risk of iatrogenic injury to the ulnar nerve. Previous clinical studies have suggested that lateral pins provide sufficient fixation of unstable supracondylar fractures. However, these studies were retrospective and subject to patient-selection bias. METHODS: A displaced supracondylar humeral fracture was fixed with only lateral-entry pins in 124 consecutively managed children. Medical records and radiographs were reviewed to identify any complications, including loss of fracture reduction, iatrogenic ulnar nerve injury, infection, loss of motion of the elbow, and the need for additional surgery. In addition, eight displaced supracondylar humeral fractures that had been reduced and fixed with lateral pins at other institutions and had lost reduction were analyzed to determine the causes of the failures. RESULTS: Sixty-nine children had a type-2 fracture, according to Wilkins's modification of Gartland's classification system; forty-three (62%) of those fractures were stabilized with two pins and twenty-six (38%), with three pins. Fifty-five children had a type-3 fracture; nineteen (35%) of those fractures were stabilized with two pins and thirty-six (65%), with three pins. A comparison of perioperative and final radiographs showed no loss of reduction of any fracture. There was also no clinically evident cubitus varus, hyperextension, or loss of motion. There were no iatrogenic nerve palsies, and no patient required additional surgery. One patient had a pin-track infection. Our analysis of the eight clinical and radiographic failures of lateral pin fixation that were not part of the consecutive series showed that the loss of fixation was due to fundamental technical errors. CONCLUSIONS: In this large, consecutive series without selection bias, the use of lateral-entry pins alone was effective for even the most unstable supracondylar humeral fractures. There were no iatrogenic ulnar nerve injuries, and no reduction was lost. The important technical points for fixation with lateral-entry pins are (1) maximize separation of the pins at the fracture site, (2) engage the medial and lateral columns proximal to the fracture, (3) engage sufficient bone in both the proximal segment and the distal fragment, and (4) maintain a low threshold for use of a third lateral-entry pin if there is concern about fracture stability or the location of the first two pins. |
| Author | Cluck, Michael W. Kay, Robert M. Mostofi, Amir Flynn, John M. Skaggs, David L. |
| AuthorAffiliation | 1 Division of Orthopaedic Surgery, Childrens Hospital Los Angeles, Mailstop 69, 4650 Sunset Boulevard, Los Angeles, CA 90027. E-mail address for D.L. Skaggs: dskaggs@chla.usc.edu |
| AuthorAffiliation_xml | – name: 1 Division of Orthopaedic Surgery, Childrens Hospital Los Angeles, Mailstop 69, 4650 Sunset Boulevard, Los Angeles, CA 90027. E-mail address for D.L. Skaggs: dskaggs@chla.usc.edu |
| Author_xml | – sequence: 1 givenname: David surname: Skaggs middlename: L. fullname: Skaggs, David L. organization: 1 Division of Orthopaedic Surgery, Childrens Hospital Los Angeles, Mailstop 69, 4650 Sunset Boulevard, Los Angeles, CA 90027. E-mail address for D.L. Skaggs: dskaggs@chla.usc.edu – sequence: 2 givenname: Michael surname: Cluck middlename: W. fullname: Cluck, Michael W. – sequence: 3 givenname: Amir surname: Mostofi fullname: Mostofi, Amir – sequence: 4 givenname: John surname: Flynn middlename: M. fullname: Flynn, John M. – sequence: 5 givenname: Robert surname: Kay middlename: M. fullname: Kay, Robert M. |
| BackLink | http://pascal-francis.inist.fr/vibad/index.php?action=getRecordDetail&idt=15598654$$DView record in Pascal Francis https://www.ncbi.nlm.nih.gov/pubmed/15069133$$D View this record in MEDLINE/PubMed |
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| Cites_doi | 10.2106/00004623-199402000-00013 10.2106/00004623-200105000-00013 10.1097/01241398-199307000-00019 10.5435/00124635-199701000-00003 10.1097/01241398-199809000-00027 10.1097/01241398-199103000-00010 10.1097/01241398-199201000-00002 10.1097/00003086-200007000-00008 10.1148/128.1.145 10.1097/01241398-199207000-00015 10.1097/01241398-199507000-00004 10.1097/01202412-199704000-00006 10.1097/01241398-200101000-00007 |
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| Keywords | Human Fixation Treatment Pin Supracondylar fracture Lateral Orthopedics Diseases of the osteoarticular system Rheumatology Humerus Child |
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| References | (R12-6-20170125) 1978; 128 (R9-6-20170125) 1993; 13 (R11-6-20170125) 1997; 5 (R15-6-20170125) 2001; 21 (R1-6-20170125) 2001; 83 (R10-6-20170125) 1995; 44 (R19-6-20170125) 2000; 376 (R16-6-20170125) 2002; 22 (R4-6-20170125) 1992; 12 (R13-6-20170125) 1997; 6 (R14-6-20170125) 1991; 11 (R3-6-20170125) 1998; 18 (R2-6-20170125) 1998; 18 (R18-6-20170125) 1992; 12 (R5-6-20170125) 1995; 15 (R8-6-20170125) 2001; 21 (R17-6-20170125) 1994; 76 |
| References_xml | – volume: 18 start-page: 43 year: 1998 ident: R2-6-20170125 publication-title: J Pediatr Orthop – volume: 76 start-page: 253 year: 1994 ident: R17-6-20170125 publication-title: J Bone Joint Surg Am doi: 10.2106/00004623-199402000-00013 – volume: 21 start-page: 313 year: 2001 ident: R15-6-20170125 publication-title: J Pediatr Orthop – volume: 22 start-page: 440 year: 2002 ident: R16-6-20170125 publication-title: J Pediatr Orthop – volume: 83 start-page: 735 year: 2001 ident: R1-6-20170125 publication-title: J Bone Joint Surg Am doi: 10.2106/00004623-200105000-00013 – volume: 13 start-page: 521 year: 1993 ident: R9-6-20170125 publication-title: J Pediatr Orthop doi: 10.1097/01241398-199307000-00019 – volume: 44 start-page: 199 year: 1995 ident: R10-6-20170125 publication-title: Instr Course Lect – volume: 5 start-page: 19 year: 1997 ident: R11-6-20170125 publication-title: J Am Acad Orthop Surg doi: 10.5435/00124635-199701000-00003 – volume: 18 start-page: 686 year: 1998 ident: R3-6-20170125 publication-title: J Pediatr Orthop doi: 10.1097/01241398-199809000-00027 – volume: 11 start-page: 191 year: 1991 ident: R14-6-20170125 publication-title: J Pediatr Orthop doi: 10.1097/01241398-199103000-00010 – volume: 12 start-page: 11 year: 1992 ident: R18-6-20170125 publication-title: J Pediatr Orthop doi: 10.1097/01241398-199201000-00002 – volume: 376 start-page: 49 year: 2000 ident: R19-6-20170125 publication-title: Clin Orthop doi: 10.1097/00003086-200007000-00008 – volume: 128 start-page: 145 year: 1978 ident: R12-6-20170125 publication-title: Radiology doi: 10.1148/128.1.145 – volume: 12 start-page: 494 year: 1992 ident: R4-6-20170125 publication-title: J Pediatr Orthop doi: 10.1097/01241398-199207000-00015 – volume: 15 start-page: 435 year: 1995 ident: R5-6-20170125 publication-title: J Pediatr Orthop doi: 10.1097/01241398-199507000-00004 – volume: 6 start-page: 110 year: 1997 ident: R13-6-20170125 publication-title: J Pediatr Orthop B doi: 10.1097/01202412-199704000-00006 – volume: 21 start-page: 27 year: 2001 ident: R8-6-20170125 publication-title: J Pediatr Orthop doi: 10.1097/01241398-200101000-00007 |
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| Snippet | BackgroundThere has been controversy regarding the optimal pin configuration in the management of supracondylar humeral fractures in children. A crossed-pin... There has been controversy regarding the optimal pin configuration in the management of supracondylar humeral fractures in children. A crossed-pin... BACKGROUND: There has been controversy regarding the optimal pin configuration in the management of supracondylar humeral fractures in children. A crossed-pin... |
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| SubjectTerms | Adolescent Biological and medical sciences Bone Nails Child Child, Preschool Diseases of the osteoarticular system Female Fracture Fixation - instrumentation Fracture Fixation - methods Humans Humeral Fractures - surgery Infant Male Medical sciences Practice Guidelines as Topic Retrospective Studies Treatment Outcome |
| Title | Lateral-Entry Pin Fixation in the Management of Supracondylar Fractures in Children |
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